933 resultados para First Christian Church (Colby, Kan.). Maids and Matrons.


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BACKGROUND: With many atypical antipsychotics now available in the market, it has become a common clinical practice to switch between atypical agents as a means of achieving the best clinical outcomes. This study aimed to examine the impact of switching from olanzapine to risperidone and vice versa on clinical status and tolerability outcomes in outpatients with schizophrenia in a naturalistic setting. METHODS: W-SOHO was a 3-year observational study that involved over 17,000 outpatients with schizophrenia from 37 countries worldwide. The present post hoc study focused on the subgroup of patients who started taking olanzapine at baseline and subsequently made the first switch to risperidone (n=162) and vice versa (n=136). Clinical status was assessed at the visit when the first switch was made (i.e. before switching) and after switching. Logistic regression models examined the impact of medication switch on tolerability outcomes, and linear regression models assessed the association between medication switch and change in the Clinical Global Impression-Schizophrenia (CGI-SCH) overall score or change in weight. In addition, Kaplan-Meier survival curves and Cox-proportional hazards models were used to analyze the time to medication switch as well as time to relapse (symptom worsening as assessed by the CGI-SCH scale or hospitalization). RESULTS: 48% and 39% of patients switching to olanzapine and risperidone, respectively, remained on the medication without further switches (p=0.019). Patients switching to olanzapine were significantly less likely to experience relapse (hazard ratio: 3.43, 95% CI: 1.43, 8.26), extrapyramidal symptoms (odds ratio [OR]: 4.02, 95% CI: 1.49, 10.89) and amenorrhea/galactorrhea (OR: 8.99, 95% CI: 2.30, 35.13). No significant difference in weight change was, however, found between the two groups. While the CGI-SCH overall score improved in both groups after switching, there was a significantly greater change in those who switched to olanzapine (difference of 0.29 points, p=0.013). CONCLUSION: Our study showed that patients who switched from risperidone to olanzapine were likely to experience a more favorable treatment course than those who switched from olanzapine to risperidone. Given the nature of observational study design and small sample size, additional studies are warranted.

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Aim of this thesis was to design and manufacture a microdistillation column. The literature review part of this thesis covers stainless steels, material processing and basics about engineering design and distillation. The main focus, however, is on the experimental part. Experimental part is divided into five distinct sections: First part is where the device is introduced and separated into three parts. Secondly the device is designed part by part. It consists mostly of detail problem solving, since the first drawings had already been drawn and the critical dimensions decided. Third part is the manufacture, which was not fully completed since the final assembly was left out of this thesis. Fourth part is the test welding for the device, and its analysis. Finally some ideas for further studies are presented. The main goal of this thesis was accomplished. The device only lacks some final assembly but otherwise it is complete. One thing that became clear during the process was how difficult it is to produce small and precise steel parts with conventional manufacturing methods. Internal stresses within steel plates and thermal distortions can easily ruin small steel structures. Designing appropriate welding jigs is an important task for even simple devices. Laser material processing is a promising tool for this kind of steel processing because of the flexibility, good cutting quality and also precise and low heat input when welding. Next step in this project is the final assembly and the actual distillation tests. The tests will be carried out at Helsinki University of Technology.

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Fluent health information flow is critical for clinical decision-making. However, a considerable part of this information is free-form text and inabilities to utilize it create risks to patient safety and cost-­effective hospital administration. Methods for automated processing of clinical text are emerging. The aim in this doctoral dissertation is to study machine learning and clinical text in order to support health information flow.First, by analyzing the content of authentic patient records, the aim is to specify clinical needs in order to guide the development of machine learning applications.The contributions are a model of the ideal information flow,a model of the problems and challenges in reality, and a road map for the technology development. Second, by developing applications for practical cases,the aim is to concretize ways to support health information flow. Altogether five machine learning applications for three practical cases are described: The first two applications are binary classification and regression related to the practical case of topic labeling and relevance ranking.The third and fourth application are supervised and unsupervised multi-class classification for the practical case of topic segmentation and labeling.These four applications are tested with Finnish intensive care patient records.The fifth application is multi-label classification for the practical task of diagnosis coding. It is tested with English radiology reports.The performance of all these applications is promising. Third, the aim is to study how the quality of machine learning applications can be reliably evaluated.The associations between performance evaluation measures and methods are addressed,and a new hold-out method is introduced.This method contributes not only to processing time but also to the evaluation diversity and quality. The main conclusion is that developing machine learning applications for text requires interdisciplinary, international collaboration. Practical cases are very different, and hence the development must begin from genuine user needs and domain expertise. The technological expertise must cover linguistics,machine learning, and information systems. Finally, the methods must be evaluated both statistically and through authentic user-feedback.

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The front end of innovation is regarded as one of the most important steps in building new software products or services, and the most significant benefits in software development can be achieved through improvements in the front end activities. Problems in the front end phase have an impact on customer dissatisfaction with delivered software, and on the effectiveness of the entire software development process. When these processes are improved, the likelihood of delivering high quality software and business success increases. This thesis highlights the challenges and problems related to the early phases of software development, and provides new methods and tools for improving performance in the front end activities of software development. The theoretical framework of this study comprises two fields of research. The first section belongs to the field of innovation management, and especially to the management of the early phases of the innovation process, i.e. the front end of innovation. The second section of the framework is closely linked to the processes of software engineering, especially to the early phases of the software development process, i.e. the practice of requirements engineering. Thus, this study extends the theoretical knowledge and discloses the differences and similarities in these two fields of research. In addition, this study opens up a new strand for academic discussion by connecting these research directions. Several qualitative business research methodologies have been utilized in the individual publications to solve the research questions. The theoretical and managerial contribution of the study can be divided into three areas: 1) processes and concepts, 2) challenges and development needs, and 3) means and methods for the front end activities of software development. First, the study discloses the difference and similarities between the concepts of the front end of innovation and requirements engineering, and proposes a new framework for managing the front end of the software innovation process, bringing business and innovation perspectives into software development. Furthermore, the study discloses managerial perceptions of the similarities and differences in the concept of the front end of innovation between the software industry and the traditional industrial sector. Second, the study highlights the challenges and development needs in the front end phase of software development, especially challenges in communication, such as linguistic problems, ineffective communication channels, a communication gap between users/customers and software developers, and participation of multiple persons in software development. Third, the study proposes new group methods for improving the front end activities of software development, especially customer need assessment, and the elicitation of software requirements.

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A culture of P. brasilianum, isolated from soil collected at the Serra do Cipó National Park, in Minas Gerais State (Brazil), was grown for 25 days on a dextrose-peptone-salts medium. The corresponding ethylacetate extract was column chromatographed and four compounds were isolated: austin, dehydroaustin, D-mannitol and penicillic acid. This is, in the best of our knowledge, the first time that the meroterpenes austin and dehydroaustin have been isolated from this species. Activity of the extract and isolated compounds was tested against six bacteria and for acetylcholinesterase inhibition. Penicillic acid showed high activity in both tests.

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Väitöskirjassa tarkastellaan kouluikäisten lasten ja nuorten sosiaalisen kompetenssin ja yksinäisyyden mittaamista, yhteyksiä ja periytyvyyttä vanhemmilta heidän lapsilleen. Alakouluikäisten lasten tutkimusaineisto (n=985) koostuu lapsilta itseltään, heidän luokkatovereiltaan, opettajiltaan ja vanhemmiltaan vuosina 2000 - 2004 osana Merkitystä etsimässä – tutkimusprojektia (M. Vauras) kerätystä aineistosta. Mukana on itse-, toveri-, opettaja- ja vanhempien arviot lasten sosiaalisesta kompetenssista, seuranta-aineisto lasten yksinäisyydestä, opettajien arviot lasten motivationaalisesta orientaatiosta, standardoiduin testisarjoin arvioidut akateemiset taidot sekä lasten äitien ja isien arviot omasta yksinäisyydestään ja koetusta kyvykkyydestään toimia vanhempana. Yläkouluikäisten nuorten (n=386) aineisto koostuu vuosina 2006 – 2007 osana Sosioemotionaalinen oppiminen ja hyvinvointi yläkouluyhteisössä (P. M. Niemi) kerätystä nuorten yksinäisyyden, sosiaalisen ahdistuneisuuden ja sosiaalisen fobian seuranta-aineistosta. Mitattavuutta (päätavoite 1) tutkittiin erityisesti monitahoarviointien rakenteiden yhtenäisyyksiä, subjektiivisten arvioiden ajallista pysyvyyttä sekä mittareiden validiteettia ja reliabiliteettia testaamalla. Sosiaalisen kompetenssin ja yksinäisyyden keskinäisten yhteyksien lisäksi tarkasteltiin näiden yhteyttä alakoululaisten oppimiseen sekä yläkou¬lulaisten psykososiaaliseen hyvinvointiin (päätavoite 2). Kolmantena päätavoitteena oli selvittää yksinäisyyden mahdollista periytymistä vanhemmilta lapsille. Osana ensimmäistä päätavoitetta kehitettiin Monitahoarviointi sosiaalisesta kompetenssista (MASK) -arviointimenetelmä (artikkeli 1). Konfirmatorisen faktorianalyysin tulosten perusteella nelifaktorinen rakenne (prososiaalisuus sisältäen yhteistyötaidot ja empatiakyvyn sekä antisosiaalisuus sisältäen impulsiivisuuden ja häiritsevyyden) sopi sekä lasten itsensä, heidän luokkatovereidensa, opettajiensa että vanhempiensa tekemiin arviointeihin. Eri tahojen arviointien väliset korrelaatiot olivat tilastollisesti merkitseviä, joskin suhteellisen matalia, ts. eri tahojen näkökulmat lapsen sosiaalisesta kompetenssista ovat toisistaan eriäviä. Täten eri arvioitsijatahojen käyttäminen on kokonaisuuden tutkimisen kannalta tärkeää. Toisena mittaamiseen liittyvänä tavoitteena oli validoida Hozan, Bukowskin ja Beeryn (2000) sosiaalisen ja emotionaalisen yksinäisyyden mittari suomalaisille lapsille (artikkeli 3) ja nuorille (artikkeli 4) soveltuvaksi sekä tutkia, ovatko lasten ja nuorten arviot omasta yksinäisyydestään ajallisesti pysyviä. Alakoululaisten lasten osalta yksinäisyys, erityisesti sosiaalinen yksinäisyys osoittautui suhteellisen pysyväksi, mutta vahvistui entisestään yläkouluikäisten nuorten aineistoa tarkasteltaessa. Huomionarvoista sekä ala- että yläkoululaisten aineistoissa oli poikien kokema vahva emotionaalinen yksinäisyys. Molempien mittareiden osalta sekä validiteetti että reliabiliteetti todettiin hyväksyttäväksi ja niitä voidaan suositella lasten ja nuorten sosiaalisen kompetenssin ja yksinäisyyden arviointimenetelmiksi. Toisena päätavoitteena oli rakenneyhtälömallinnuksen keinoin tarkastella sosiaalisen kompetenssin ja yksinäisyyden yhteyksiä sekä keskenään (artikkelit 2 ja 3) että suhteessa lasten oppimiseen (artikkeli 2) ja nuorten psykososiaaliseen hyvinvointiin (artikkeli 4). Alakouluikäisten lasten osalta sosiaalinen kompetenssi oli yhteydessä pait¬si yksinäisyyteen myös opettajien oppilaistaan tekemiin motivationaalisen orientaation arvioihin sekä standardoiduin testien arvioituihin akateemisiin taitoihin. Yläkouluikäisten nuorten osalta yksinäisyys oli yhteydessä sosiaaliseen ahdistuneisuuteen ja sosiaaliseen fobiaan. Täten sosiaalisen kompetenssin voidaan katsoa olevan koululaisten hyvinvointia ja oppimista vahvistava, ja toisaalta yksinäisyyden nuorten psykososiaalista hyvinvointia heikentävä tekijä. Viimeisenä päätavoitteena mallinnettiin yksinäisyyden mahdollista periytyvyyttä. Ensimmäisessä vaiheessa periytyvyyttä tarkasteltiin koko perheen sisällä, vanhempien tai lasten sukupuolta erottelematta (artikkeli 2). Tässä rakenneyhtälömallissa vanhempien kokema yksinäisyys ennusti heikompaa kyvykkyydentunnetta vanhemmuudesta, joka edelleen ennusti lapsen heikompaa toveriarvioitua sosiaalista kompetenssia koulussa ja tätä kautta vahvempaa yksinäisyyden kokemusta. Toisessa mallissa eroteltiin äitien ja isien sekä tyttöjen ja poikien aineistot, jotta periytyvyyttä voitiin tarkastella äiti-tytär, äiti-poika, isä-tytär ja isä-poika dyadisuhteissa. Rakenneyhtälömallinnuksen tulosten perusteella sekä äitien että isien kokema yksinäisyys ennusti

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Succeeding in small board lot (0-20 tons) deliveries, is not always prosperous and failures as well as extra costs compared to standard costs arise. Failure deliveries from converting plants to customer locations tie a lot of unwanted and unexpected costs. Extra costs are handled as quality costs and more precise, internal failure costs. These costs revolve from unsuccessful truck payloads, redundant warehousing or unfavorable routing as examples. Quality costs are becoming more and more important factor in company’s financial decision making. Actual, realized truck payload correlates with the extra costs occurring, so filling the truck payload all get-out well is a key to lower the extra costs. Case company in this study is Corporation A, business segment Boards. Boards have outsourced half of their converting in order to gain better customer service via flexibility, lead time reductions and logistics efficiency improvements. Examination period of the study is first two quarters of year 2008 and deliveries examined are from converters to the customer locations. In Corporation A’s case, the total loss in failure deliveries is hundreds of thousands of Euros during the examination period. So, the logistics goal of getting the right product to the right place and right time for the least cost, does not completely realize.

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ABSTRACT This paper is an analysis of the manner Nishida Kitarô (1870-1945), in the process of construction of his own philosophy of religion, enters into dialogue with Leibniz's thought concerning Pre-established Harmony. Although the philosophy of religion is an important theme and Nishida goes back to Leibniz at some points in his textual career, there are relatively few studies that touch on the relationship between these two thinkers. I study Nishida's approach under three headings. The first section concerns ten main aspects of the world of pre-established harmony. The second tries to show the manner in which such a world becomes a guide towards a philosophy of religion, placing the emphasis on three characteristically Christian aspects: a created, fallen, and Trinitarian world. The third section includes some elements such as the entrance into religion, metanoia, satori and a comparison between Christian agape and Buddhist maha-kruna. These are themes on which Nishida elaborates in his 1945 masterpiece, The Logic of Basho and a Religious Worldview.

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The most important knowledge in firms is mostly tacit and embedded in individuals within the organization. This background knowledge that firms possess is used for creation of new knowledge and innovations. As firms today greatly concentrate on their core competencies, they need external knowledge from various collaboration partners. Thus, collaborative relationship governance, as well as control (use of appropriability mechanisms) over background (the input from each firm in innovative activities) and foreground knowledge (the output of collaboration activities) is needed in order to successfully create and capture value from innovative activities without losing core knowledge and competitiveness. Even though research has concentrated on knowledge protection and knowledge sharing, studies that combine both of these views and examine the effects of sharing and protection on value creation and capture have been rather limited. Studies have mainly focused on the protection of the output of innovation while forgetting the protection of the input of innovation. On the other hand, as the research concentrating on the output of innovation tends to favor formal mechanisms, informal mechanisms have remained more unknown to researchers as well as managers. This research aims to combine the perspectives of knowledge sharing and knowledge protection and their relationship with value creation and value capture. The sharing and protection are viewed from two points of view: the use of appropriability mechanisms, as well as governance of the collaborative relationship. The study consists of two parts. The first part introduces the research topic and discusses the overall results. The second part comprises six complementary research publications. Both qualitative and quantitative research methods are used in the study. In terms of results, the findings enhance understanding of the combined use of formal and informal mechanisms for knowledge protection and sharing. Informal mechanisms appear to be emphasized in the protection of background knowledge, and thus are prerequisites for innovation, whereas formal mechanisms are relied on more for protecting the results of innovative activities. However, the simultaneous use of the formal and informal mechanisms that are relevant to the particular industry and innovation context is recommendedthroughout the collaborative innovation process. Further, the study adds to the current knowledge on HRM as an appropriability mechanism: on the firm level its uses include assessing and hedging against employee-related risks such as knowledge leaking and knowledge leaving. A further contribution is to the research on HRM protection and its interrelations with other appropriability mechanisms, its constituents, and its potential use in the area of knowledge protection.

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Planting densities influence several aspects of forest formation, including management practices, timber yield, quality, and extraction, and consequently its production costs. The objective of this study was to evaluate Mimosa caesalpiinifolia and Gliricidia sepium growth as a function of planting density (400, 600, 800, 1000, and 1200 plants ha-1) and plant age. The species were evaluated every 90 days for plant height (PH), crown diameter (CD) and root collar diameter (RCD) (10 cm above the ground), with the first evaluation performed at 90 days and the last at 720 days. When plants were one year of age and beyond, evaluations were conducted also for stem diameter at breast height (DBH) (1.30 m above the ground). A randomized block design with split-plots and three replicates was adopted. Species were assigned to plots, planting densities were assigned to subplots, and evaluation ages were assigned to subsubplots. The four traits in both species had their values decreased as planting density increased, but continually increased as plant age increased. For PH and RCD there was an alternation between species superiority, with gliricidia being superior to sabiá at some ages, while the opposite occurred at other ages. As to CD the species only differed in the last measurement, gliricidia being superior. With regard to DBH, gliricidia was superior starting from the second measurement. There was an effect of the species × ages interaction for the four traits and also an effect of the densities × ages interaction for CD and DBH.

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The evaluation of technologies employed at the agricultural production system such as crop rotation and soil preparation, both associated with crop-livestock integration, is crucial. Therefore, the aim of the present study was to evaluate the incorporation of lime for three no-tillage systems and cultural managements in system of crop-livestock integration, with emphasis on corn grain yield. The experiment was conducted from January 2003 to April 2005 at Selvíria city, MS, in Dystroferric Red Latosol, clay texture. The experimental design was randomized blocks with split plots consisted of three main treatments, aimed the soil physics conditioning and the incorporation of lime: PD - No-no-tillage; CM - minimum no-tillage, and PC - conventional no-tillage; and of two secondary treatments related to the management: rotation and crop succession, with four replications. Data on agronomic traits of maize were analyzed: plant height, stem diameter, height of the first spike insertion, 100 grains weight and grain yield. The results showed that the maize produced under the system of crop-livestock integration is quite feasible, showing that grain yields are comparable to averages in the region and the different soil physical conditioning and incorporation of lime did not influence the corn yield as well as the cultural managements, rotation and succession, did not affect the maize crop behavior after two years of cultivation.

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ABSTRACT The present study aims to present the main concepts of the sugarcane straw to energy planning. Throughout the study, the subject is contextualized highlighting broader aspects of sustainability, which is considered the main driver towards agro-energy modernization. Concerning sugarcane straw, we first evaluated its availability regarding technical and economic aspects, and then it summarized the straw production chain for energy supply purposes. As a proposal to support agro-energy planning, it is presented some spatial tools that have been barely used in the Brazilian energy planning context so far. Therefore, working on straw to electricity associated with supply chain basis, we developed a conceptual model to spatially assess this bioenergy system. Using the model proposed, it is described the whole supply chain at state level, which accounted the potential of a single mill to explore straw, as well as main costs associated with straw acquisition, investments on the straw recovery routes and electricity transmission. Bearing these concepts in mind, it is fully believed that spatial analysis can bring important information for agro-energy action plans.

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Prostate-specific antigen (PSA) is a marker that is commonly used in estimating prostate cancer risk. Prostate cancer is usually a slowly progressing disease, which might not cause any symptoms whatsoever. Nevertheless, some cases of cancer are aggressive and need to be treated before they become life-threatening. However, the blood PSA concentration may rise also in benign prostate diseases and using a single total PSA (tPSA) measurement to guide the decision on further examinations leads to many unnecessary biopsies, over-detection, and overtreatment of indolent cancers which would not require treatment. Therefore, there is a need for markers that would better separate cancer from benign disorders, and would also predict cancer aggressiveness. The aim of this study was to evaluate whether intact and nicked forms of free PSA (fPSA-I and fPSA-N) or human kallikrein-related peptidase 2 (hK2) could serve as new tools in estimating prostate cancer risk. First, the immunoassays for fPSA-I and free and total hK2 were optimized so that they would be less prone to assay interference caused by interfering factors present in some blood samples. The optimized assays were shown to work well and were used to study the marker concentrations in the clinical sample panels. The marker levels were measured from preoperative blood samples of prostate cancer patients scheduled for radical prostatectomy. The association of the markers with the cancer stage and grade was studied. It was found that among all tested markers and their combinations especially the ratio of fPSA-N to tPSA and ratio of free PSA (fPSA) to tPSA were associated with both cancer stage and grade. They might be useful in predicting the cancer aggressiveness, but further follow-up studies are necessary to fully evaluate the significance of the markers in this clinical setting. The markers tPSA, fPSA, fPSA-I and hK2 were combined in a statistical model which was previously shown to be able to reduce unnecessary biopsies when applied to large screening cohorts of men with elevated tPSA. The discriminative accuracy of this model was compared to models based on established clinical predictors in reference to biopsy outcome. The kallikrein model and the calculated fPSA-N concentrations (fPSA minus fPSA-I) correlated with the prostate volume and the model, when compared to the clinical models, predicted prostate cancer in biopsy equally well. Hence, the measurement of kallikreins in a blood sample could be used to replace the volume measurement which is time-consuming, needs instrumentation and skilled personnel and is an uncomfortable procedure. Overall, the model could simplify the estimation of prostate cancer risk. Finally, as the fPSA-N seems to be an interesting new marker, a direct immunoassay for measuring fPSA-N concentrations was developed. The analytical performance was acceptable, but the rather complicated assay protocol needs to be improved until it can be used for measuring large sample panels.

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Ipomoea sericophylla and Ipomoea riedelii cause a glycoprotein storage disease in goats. This paper reports the experimental poisoning in goats by dried I. sericophylla and I. riedelii containing 0.05% and 0.01% swainsonine, respectively. Three groups with four animals each were used. Group 1 received daily doses of 2g/kg body weight (bw) of dried I. sericophylla (150mg of swainsonine/kg). Goats from this group had clinical signs 36-38 days after the start of ingestion. Group 2 received dried I. riedelii daily doses of 2g/kg of I. riedelii (30mg of swainsonine/kg) for 70 days. No clinical signs were observed, therefore the swainsonine dose was increased to 60mg/kg for another 70 days. Goats from Group 2 had clinical signs 26-65 days after increase in swainsonine dose to 60mg/kg. Group 3 was used as control. In these experiments the minimum toxic dose was 60mg/kg which represents 0.0004% of the dry matter in goats ingesting 1.5% bw of the dry matter. For goats ingesting 2%-2.5% bw of dry matter this dose would be 0.00024%-0.0003% of the dry matter. After the end of the experiment two goats were euthanized and another six were observed for recovery of clinical signs. Four goats that continued to consume swainsonine containing plant for 39-89 days after the first clinical signs had non reversible signs, while two goats that ingested the plant for only 15 and 20 days after the first clinical signs recovered completely. These and previous results indicate that irreversible lesions due to neuronal loss occur in goats that continue to ingest the plants for about 30 days after the first clinical signs. Clinical signs and histological lesions were similar to those reported previously for goats poisoned by swainsonine containing plants. No significant alterations were found in packed cell volume, red and white blood cell counts, hemoglobin and mean corpuscular hemoglobin concentrations, mean corpuscular volume, and serum levels of glucose, total protein, and albumin, and the serum activities of gamma glutamyl transferase and aspartate aminotransferase. Swainsonine concentration of 0.05% in I. sericophylla and 0.01% in I. riedelii are different from samples of these plants used in previous experiments, which contained 0.14% and 0.5% swainsonine, respectively, demonstrating a wide variation in the toxicity of different samples.

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Pain in animals has been recognized for less than one century. Several authors confirm that animals are capable to process, register and modulate nociceptive stimuli in a very similar way to human kind and there are several evidences registering the impact of pain sensation over vital systems interfering on disease outcome. Nevertheless, despite some evidences that animals, as human beings, can store information from past painful experiences less is known about how this so called pain memory works. The aims of this study were: to evaluate if the response to a painful stimuli differs during different stages of life and if repetition of a same acute stimuli in the same animal interferes with expression of hyperalgesia. Thus, 60 rats were selected and arranged in 3 equal groups: 3 months, 6 months, and 9 months of age. All animals were injected 5% formalin solution in the plantar face of hind paw under volatile general anesthesia. Von Frey filaments were applied at 1h, 24h and 48h after sensitization. Injection was repeated twice with a 30-day interval, each time in a different hind paw. Results showed that younger rats express lower hyperalgesia thresholds in the first stimulation compared to elder animals and that repetition of same stimulus diminishes hyperalgesia thresholds when it begins during infant period and augments hyperalgesia thresholds when it begins during elder ages.